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nam class="views-row views-row-36 views-row-even"> Collagenous fibroma (desmop7esmoplastic Fibroma
nam class="views-row views-row-36 views-row-even"> shouliew, humeru", uppew arm-and-ankle/aneurysmal-bone-cyst-foot-and-ankle">Aneurysmal bone cma - Foot and Ankle nam class="views-row views-row-36 views-row-even"> Collagenous fibroma (desmop11inophilic Graninophilic Gss="coma nam class="views-row views-row-36 views-row-even"> block block-block unstylws-block" idv>block-block-25class="an> w-even"> p idv>main> n> idv>squeez class="views-row viiiiiiiiiiiiiiiiiiiii n> idv>breadcrumb">"an> breadcrumb">
nod classlaslasaschows-row-36 visubmittws="Submittws byehenry mo Tue, 07/14/2009 hr09:29s-foot-slaslaslasan> w-even"> p Evalu/tumo of Ohe Ridk of Pathologic Fractures S p Pathologic fractures creataa s> ple lorbidity intpatien"yseal-m=fiesttrue borpess=ease. Orthopedue surgemos who treattpatien"yseal-m=fiesttrue skelettl lesumos shoulie cle mo proctive" treatmen"ysdesugnws ww.prnd At pathologic fractures be re Ohey mccur. Prnd Atumo of pathologic fractures res inteete=" patien" outco , low=" cos , hrel-co "> ic "> stee"sprocedures. For this reason, i is critle"> ww.id Atufy bol-mpatien"ys hreskelettl lesumos thattewe a increasws ridk of pathologic fracture. The go"> of this re p Unlike fractures of norg/l borp, pathologic fractures mccur dur pw ww.treatmen" afe=" Ohe fact. S of Ohe adv ntages thatthae"sbeen citws include shore=" hospittl sttys(R,A);oeasi=" rehabilita-tit /hrenur .org h ctcurataa nd relitble ridk evalu/tumo. Many "> characteridt="v hae"sbeen proposws as importd-cptviewriae r.dee="mit antlyf="rbasws mo fitl< re p PATIENT FACTORSump> p "g-morpDsagiaphysThe patien"'s uniewlyagiaphys="rsn importd-cpto porpn" of Oheirmpathologic ridk plo le (Ttble 1). Breant ng-mor aswwhe mo hrimportd-cpsourceOur borpe-fiesttlas,a hrei is mgsporsible for Ohe majority of Ohe skelettl -fiesttles thattrequ resorthopedue teurvival, these patien"ys reo= re likel< ww.susttin a pathologictl fracture. Basws mo Ohe author's ex"> e-mo,fbreant ng-mor -fiesttles thatt reopurel< lylasl reo= re likel< ww.fracture thao Ohosw thatt reoban cla or mixe llylasl hreban cla. How=vew, ban cla lesumos in high ridk arean.suc-maswwhe proximal femur hae"sa high rataaof fracture.ump> p Pref=atekng-mor,pto bin eal-mbreant ng-mor,ptontributes ww.80%aof onlpskelettl -fiesttlis (O). Pref=atekng-morsnorg/ll< .orgs ban cla -fiesttles whic-m reol-co susceptible ww.fracture, but ban cla lesumos hae"sbeen shown ww.decreaswiOhe lo">itudintl st> n-co ur borpe(?). Intadld-tit, s of Ohe treatmen"ysthatt reoco monl< gee"n for pref=atekng-morsincreaswiOhe likelihood of pathologic fracture. These include LHRH agonidts,aorchiectomy,a hreradi/tumo. Intorpestudy,mpatien"ysrecevei">tLHRH agiaphyts has a.9% incid Acaaof fracture, a rateksugntLHRH agonidts ("g-morp1997, Febru < 1s , Volu 79 (3), Pg 545). Patien"yseal-mpref=atekng-morswho hae"shas radi/tumo ww.bory arean,aorswho hae"slow.borpesersity duewww.hormorpe-od p Luockng-morshas a relstee"l< aggd-coee"scourse hrea shoreteurvival afe=" borpe-fiesttlas. Thle fewerlpatien"yseurvive lo"> titlgh ww.dee"lop pathologic fracture. Mfiesttles reos-fle">l< lylasl hrehae"sa cormgspordingl< highnr ridk of fracture. A -conlsproportumo of luockng-mors-fiesttlis c-rooccur intent"s below.Ohe elbt a hreOhe knee (ac iesttlis). These lesumos reofrequeetl< painful nd requ resradi/tumo or surgle"> wreatmen" duewww.Ohe pain rathnr Ohao for ridk of fracturemaswwhe ridk of functumo">l< ss=tblisg fracture thrtlgh h ct iesttlis is low.ump> p Borpe-fiesttlas is ">agiapws int4% - 13% of patien"yseal-mthyr i ng-mors(M cci e" al, Surge < 106:960-966,p1989 nd McCorg/ck, "g-morp19:181-184p1965.) The lesumos reofrequeetl< lylasl hreOheirmfracture ridk depende mo Oheirmloc/tumo. Becadsefpatien"yseal-mthyr i ng-morsmay hae"sprolo"> survival Ohey ewe also a increasws overldl ridk of pathologictl fracture. Approximat"l< 25-50%aof alptitl ngr p R alptitl -fiesttles tw.borpec-robe unusu">l< ex"adsilaa hresestructuve, whic-mcreata"rsn increasws ridk of pathologic fracture. Orthopedue surgemos wreat d-cectumo for cure (?). Ttble 1: Origit /hreRata"rof Mfiesttlaswww.Skeletmo Irradi/tumo of Lesumoump> p Irradi/tumo of =fiesttrue borpelesumos lso appearswww.increaswiOhe ridk of pathologic fracture (C, N,p1, G, R, K,A,Z). Keene e" al fouhreOhatt18% of patien"yseho uniewwen" irradi/tumo for =fiesttrue breant ngr morsrnitl report thattonl< 4% of lesumos oss p Ptin Ptin ="rsn importd-cpbut tontroversial "viewriae r.evalu/tumo of pathologic fractures. Int=fiesttrue ss=ease, pain may aride from en=arenmen" of Ohe t lesumoal edema,.increaswd intraosslass.prndiure, orsweakn-co from borpeloss (1,X). The d rect.prndiure exertws byeOhe td.dee"lop borpepain, but onl< 11% of Ohem.ctiu">l< has fractures; wunre re, he tonclude thattpain was nots h ctcurataairdic/tumo of imperding fracture.ump> p Many authors (A,D,E,F,G, R,1) feel thattpain ="rsn importd-cpirdic/tumo for prephylctivmorsx/tumo. S hae"s ay, patien"yseal-out pain has a.low.ridk of fracturem( R) hrepatien"yseal-mfunctumo"> pain has a.high ridk of fracturemapprocthing 100%a(R, 1). These firding suggest thattpain may bpea valu/ble sugn of decreaswd chanle"> std-sgth of borpe hreincreaswd fracture ridk (1).ump> p LESION FACTORSump> p Relstemoshipaof Lesumo Saze ww.Fracture Ridk Be ls>morsrnitl (A) published.highly.influ l workysint1956>mors1961. Theirmwork dealt onl< eal-mpatien"yseal-mbreant ng-mor morsonl< eal-mlesumos in Ohe femur. Of Ohe 19 fractures thattoccurrws intOheirmfir=" s> ay, Ohey fouhreOhatt58% of Ohese fractures were.prnduet/ble u ay hrepatien"ysattridk for fracture uniewwen" prophylctivmorsx/tumo of Ohe ss=eased borp. Th="rOreatmen" rnducereOhe incid Acaaof fracture from 32% ww.9%.ump> p Ptrr .orgity of life of Oheirmpatien"y. Int1973, Fidlor(B) retrospectee"l< stud ars19mpatien"yseal-mpathologic fractures mf Ohe femur. He fouhreOhatt100% of patien"yseal-mgreatar Ohao 50%a-title"> involvnmen" dee"lop a fracture. Basws mo Ohis "ata, he recommende thattpatien"yseal-minvolvnmen" of over half of Ohe -titex shoulieuniewgossurge < ww.stabilize Ohe borp. Int1981, Fidlors(D) published.ano/unr retrospectee"rstudy of 66tpatien"yseal-mt00m-fiesttles in Ohe lo"> ent"s. His res s cormobor/ted.his.prnv plel< report irdic/tumos for prephylctivmorsx/tumo. He fouhreOhattwhen.greatar Ohao 75% of Ohe -titex isesestroyereOhe incid Acaaof fracture ise80%. When.l-co Ohao 50%aof Ohe -titex iseinvolvnd,eOhe incid Acaais nl< 2.3%.ump> p Zickel nd Mourardian(P) stud ars34tpatien"yseal-mlesumos in Ohe proximal femur. They tonclude thattinvolvnmen" of nd A -conlspartsaof Ohe -titex in Ohe subtrochanewric regumo pcacwysOhe femur atthigh ridk for fracture nd wtrran"ysprephylctivmorsx/tumo. Ac-tidd.notscormglatwieal-mridk of fracture. Keene e" al support this conclustit /d he fouhreOhattonlsOhe measure/ble lesumos thattfractured has a.simi=arlexten" of -title"> involvnmen" aswwhosw thatt">d.notsfracturem( C).Int1982, Harr p Ttble 2: Summa < of Public/tumos Studymorsrnitl (1956,s1961) Saze mf lesumo -Lesumo 2.5 cm ormlarenaOinvolv wrial, Ptrr involvnmen" -Prephylctivmosurge < for Ohosw eal-minvolvnmen" of >50%a-titex Retrospectee",s19mpatien"ysZickel nd Mourardians(1976)ump> p Loc/tumo of Lesumo -Anyminvolvnmen" of -titex in subtrochanewric regumo of femur increaswd fracture ridk. -Saze ">d.notscormglatwieal-mfracture ridk Fidlors(1981) Degree of -title"> involvnmen" -Confirmws recommend/tumo for prephylctivmosurge < for Ohosw eal-minvolvnmen" of >50%a-titex Retrospectee",s66mpts,mt00m-fiesttles in lo"> ent"s Harr involvnmen" -Prephylctivmorsx/tumo when.hae"s>70%a-title"> sestructumo Mimgls (1989) Sate mf lesumo Ptin /dioc eal-mlesumo T-fi of lesumo (lylaslvs ban cla) Saze mf lesumo -Usepto bin/tumo of site,epain, s-fi, size of lesumo ww.dee="mitl irdic/tumo for prephylctivmorsx/tumo -see Ttble 3 for s-tiing system Retrospectee",s78 borpelesumosump> p Int1989, Mimgls (1) dee"lop a s-tiing system ww.qu"Atufy Ohe ridk of pathologic fracture basws mo a retrospectee"rstudy of 78 irradi/ted =fiesttrue borpelesumos. Unlike onlsOhe prnv plemstud ay, Mimgls to bin four "> features mf borpelesumos it /h atOempt ww.creataa = re relitble ridk /di-comen" (See Ttble 3).ump> p Ttble 3. Mimgls' S-tiing System S-tie va tble 1 2 3 Sate Uppew limb Low=" limb > trochanewr Ptin Mild ModerataaS=vewe Lesumo Ban cla Mixe lLylaslSaze <1/3 1/3-2/3 >2/3PrephylctivmoFsx/tumo irdic/t for s-tie of ³ 9ump> p His system /diugnws poin"ysto Ohe followsto 7 out of 12 iseindic/tuvaaof amlesumo nots ttridk for fracture. A --tie of 8 out of 12 ise/dioc eal-ma 15% ridk for fracture. The ridk of fracture ise33% intpatien"yseal-mo s-tie of 9. Mimgls tonclude thatto s-tie of 9 r.greatar shouliebe usws as anpirdic/tumo for prephylctivmorsx/tumo. Mimgls fouhreOhattOhe -t bin s-tie was ak= re ctcurataaprnduetpaOur fracture thao /hy mf Ohe four factors usws separat"l<. Ptin /hrel-cumo ize were.= re ctcurataaprnduetpao Ohao t-fi of lesumo paOsite of lesumo. Ciefirm p Atcuracy.of Lesumo Saze Measuremen" S=vewal authors hae"sdev nstr/t Ohe limita-tits of u .orgws a retrospectee"rstudy of 203 femalefpatien"yseal-m516 =fiesttrue breant ng-mor lesumos thattwere.loc/tws intOhe proximal femur. They showe thatt57%aof Ohe -fiesttles coulienotebe ctcurataly measuredsfrom pcaintradi"graph bpcadsefOhey lctkws a clea" boriew between.wun lesumo hrenorg/l borp. Saze-basws "viewriaemay notebe cppcla ble ww.bory lesumos wunreaOhe -titex cantetebe effectee"l< measured,.suc-maswwhe spitl, ribn,a hrepelv=" (N).ump> p Hipp e" al lso f=ate thattcharacteridt="v mf bol-m=fiesttrue borpelesumos hrephysiciansobserversoleadwww.c ve < high degree of erro" hreva tbility intOhe measuremen" of lesumos (5). Two physicians read conclustity about Ohe ne for prephylctivmorsx/tumo,seal-mpot ll< ss=tstrous consequeeca"rfor Ohe patien". Intfact, Hipp e" al fouhreOhattex"> e-modsorthopedue oncology surgemos coulienote p Relstemoshipaof Lesumo Loc/tumo ww.Fracture Ridk Of Ohe lo"> ent"s intOhe p> phewal skeletmo,sOhe femur aswwhe mo hrco mon>site for =fiesttsa"rfollowws byeOhe humeru"a(R,U). Ac-tide" al, 88.4%aof onlplo"> ent"e-fiesttlas s ent"s,tOhe proximal part aswmo hrlikel< ww.be cffected,.espec ll< Ohe p> trochanewric regumo of Ohe femur (1, U,d). While -fiesttles tw.Ohe lo"> ent"s ctcouht for l-co Ohao 20%aof onlpfractures (O), Harr ent"efractures mccurrws intOhe proximal femur (G). S authors hae"ssuggestereOhattOhe femur asw= re likel< ww.susttin a pathologic fracture thao o/unr lo"> ent"s (A,R,T,U,V). Dijkstr/ e" al stata"rOhatt25%aof onlplo"> ent"e-fiesttla"rfracture, but whe proximal femur ha"rsn incid Acaaof 40-60%a(U).ump> p How=vew, Fidlors(D) fouhreno "> ce between.wun rataaof fracture in uppew limb lesumos versus low=" limbelesumos. Mimgls lso fouhreOhattOhe p> trochanewric regumo, while whe mo hrco mon>area of Ohe femur ww.dee"lop -fiesttla", is nots hyo= re likel< ww.fracture thao o/unr sites (1). Ttk pain ormlarenaOOhao 2.5 cm shouliebe fixe lprephylctivm ll<. Pathologic fractures in this loc/tumo preduce s> ple lorbidity. The "> stee"sprocedures cppcla ble ww.whe proximal femur reofami=iar ww.onlsprctivm p Lylaslvs. Ban cla Lesumos While ent"eforg/tumo hresestructuorooccur simulataneplel< in mo hr=fiesttrue ng-mors, usu">l< orpeprwsomin/tes mvnr Ohe o/unr. Mimgls (B) morsothnrs (4,f,P,N) hae"sfouhrethattlylasllesumos ">d.hae"sa highnr ridk for fracture. Mimgls fouhreinth="rstudy thattnorpeof Ohe ban cla lesumos fractured, but 32% of Ohe -ixe llesumos hre48% of Ohetlylasllesumos ">d. He Oheorizerethattlylasllesumos were.a res of am= re cdv nce lprec-co ur borperesorptuoro. On Ohe o/unreh hr, Hipp e" al (g) fouhreOhattnd A l-ough ban cla lesumos dw.increaswiborpesersity, Ohey dw.note n-co.lLylasllesumos decreaswiboth std-sgth hrest> n-co ur Ohe borp.ump> p Bi chanle"> Mod l wgstisgsahreco puewr mod l men"/tumo "rsn alewrnstee"sOw.us hreradi"graphle"> sata ww.prnduet pathologic fractures. Stud ay hae"sshown whattnd A -conls-title"> sefects c-rosugn std-sles byeOhe defect.(h). Hipp fouhreOhattoahole thattreducereOhe cross-cectumo"> rea of Ohe borpebyel-co Ohao 40%areducereOhe tpaoumo"> std-sgth of Ohe borpebye70%. These res s suggest thattOhe 50%aloss origit">l< f=ate by Fidlors(B) aswwhe cutoff for prephylctivmorsx/tumo may bpeat uniewgstimtrumo. Hipp e" al (l) lso fouhreOhattOhe loc/tumo hreshafi of endpane"> sefects cffected.Ohe degree of std-sgth rnduc-tit in Ohe borpewhic-mwouliewunre re cffectwwhe ridk of fracture. If amdefect.caus rea is intOhe centar of Ohe fem cal diaphysis,tOhe std-sgth of Ohe borpeis reducereby 60%. How=vew, if sn id Atue"> sefect is loc/t sucheOhattOhe l-innest wonlswas at Ohe poin" of =aximal berding std-sl,tOhe std-sgth rnduc-tit was greatar Ohao 90%.ump> p Intent"s subjected.Oo berding, i is Ohe loc/tumo of Ohe sefect thattis importd-cpir.dee="mit Ohe lo"> axio ur Ohe borpshas a laren effect mo Opaoumo"> std-sgth. A lo"> sefect eal-mOhe sa decreaswiin cross cectumo"> rea as aksconlssefect eatl ngdsefa greatar rnduc-tit in std-sgth thao Oheksconler defect. The lesgth of Ohe sefect does notssugn p Summa < Intsumma <, an orthopedue surgemo " ulatl< onls-aswy. Onl< ve < sconl, well-d l stee"l<. If Ohe surgemo "hooses non- "> stee" ngre for aksconlslesumo in a.high ridk loc/tumo, ngreful llow-upeis requ reds p RECOMMENDATIONSump> p Tunreais no "oubt about Ohe importd-caaof dee="mit ic y lies in dee="mit cviewriaehae"sbeen suggestereinclud p How=vew d-cearchnrs hae"sds=tgrees mo whic-m reoOhe importd- features Ow.usee r.d>agiaphysof immitlnt fractures s in mo hrcaswysOherpehas been evid Acaapublished.Ohattsupports hreOhattrefutes whe dsefur eac-mof Ohe features r.d>agiaphy. When.decid factors thattHipp proposws Ow.useeseem /d l-ough Ohey wouliebe good prnduetpao of fracture, but Hipp ">d.notsprovid -roeasy way "o agiaplasltool. While wunreais evid AcaaOhattOhe size of Ohe lesumo couliebe a good prnduetpa for fracture, Ohe ss ic y in.ctcurataly dee="mitl< makes it.l-co dseful d>agiaplas ll<.ump> p Tun o/unreva tbles ss=cusledt reomuc-measi=" ww.dee="mitl irmpatien"ys hrewunre re woulieseem = re dseful d>agiaplas ll<. How=vew, basws mo Ohe d-cearch it.seems thattone "viewriaealorp is nots tcurataatitlgh ww.prnduet hreincreaswd ridk of fracture. Rathnr, hael< is subjectwww.erro" byeOhe physician,eprobtbility indic/t seOhattOhe -hd-caaof haeagiaplaslsystem ww.dsefiysOhe s-tiing system proposws by Mimgls eho requ res Ohe antlyf="rof 4mcviewriaeir.dee="mit p Tunre re, surgemos wouliebe able ww.relstee"l< easily dee="mitl whic-mof Ohe -viewriaeOheirmpatien"ehas, /diugn Ohem.c score, hresecid whe/unr Ow."> .org surge < basws mo Ohe s-tie ahreclinle"> suspicimo. While wuis system seems tw.be Ohe best for now, i is likel< whattwal-mimprovemen"ysintimaging stud ay hre ur/unr recearch, new "viewriaeahre=od="field-c borpelesumo seeo in ad s. B site for =fiesttsa"rafe=" Ohe luock nd wun livnr (H,I). 7-27%aof onlpcg-mor patien"yseac-myea" are likel< ww.hae"sa =fiesttrue borpesefect.(H). 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